=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841134301
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EPHREM WAGNER PSYD
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2026
-----------------------------------------------------
Last Update Date | 04/15/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1380 TEANECK RD APT E
-----------------------------------------------------
City | TEANECK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07666-5027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-340-0446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1380 TEANECK RD APT E
-----------------------------------------------------
City | TEANECK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07666-5027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-340-0446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 35SI00809300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------